PATIENT’S QUESTIONNAIRE

Center code ________________________________________________________________________________________________
Patient code ________________________________________________________________________________________________
Medical chart _______________________________________________________________________________________________
Gender _____________________________________________________________________________________________________
Weight ________ Height ________
Diagnosis ___________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________

1. Registrable factors

   1. Age ________
   2. Characteristics of surgery
      1. Surgery date ________
      2. Duration of surgery ________ minutes
      3. Type of surgery (select)
         1. Open upper abdominal surgery
         2. Open coloproctological surgery
         3. Open gynecological surgery
         4. Open urological surgery
         5. Open surgery on abdominal vessels
         6. Abdominal wall surgery
         7. Laparoscopic surgery
      4. Surgery risk (select)
         1. Low F Medium
         2. High
   3. Concomitant diseases
      1. Enter a history of the concomitant diseases
         1. Ischemic heart disease (functional class ________ )
         2. Arterial hypertension (stage ________, degree ________, risk ________ )
         3. Chronic cardiac failure (functional class ________ )
         4. Arrhythmias
            (specify _______________________________________________________________________________________________ )
         5. Chronic obstructive pulmonary disease ( ________ degree)
         6. Asthma ( ________ degree) F Smoking (for ________ years)
         7. Chronic renal disease ( ________ stage)
         8. Suffered cerebrovascular accident ( ________ years ago)
         9. Functionally independent patient
         10. Partially dependent patient
         11. Fully dependent patient
         12. There is hemiplegia
         13. Epilepsy
         14. Parkinson’s disease FAlzheimer’s disease FNeuromuscular diseases FDiabetes mellitu ( ________ type)
         15. Oncological diseases (select, if present)
         16. Widespread cancer (select, if present)
         17. Another disease _______________________________________________________________________________________
      2. Current medications
         1. Beta-blockers
         2. APF (angiotensin-converting enzyme) inhibitors.
            (Drug stopped before surgery? (Yes/No) If yes — stop ________ hours in advance.)
         3. Angiotensin-2 receptor blockers.
            (rug stopped before surgery? (Yes/No) If yes, stop ________ hours in advance.)
         4. Aldosterone antagonists
         5. Statins
         6. Anticoagulants/antiplatelet agents
         7. Diuretics
         8. Bronchodilators
         9. Corticosteroids systemically
         10. Insulin
         11. Oral antidiabetic drugs
         12. Anticonvulsants
         13. Iron preparations
         14. Preoperative antibiotic prophylaxis (specify drug group and duration _________________________________________ )
         15. Mechanical bowel preparation (check if performed)
      3. Risk assessment methods
         1. Integrative scales
            1. ASA physical status ________
            2. Revised Lee index ________ (points)
            3. NSQIP score, probability of a myocardial infarction or cardiac arrest ________ %
            4. Respiratory Complications Risk Scale ________ (points)
            5. MELD csore (in presense of hepatic failure) ________
            6. Shtange test ________ seconds
            7. Cognitive status ________ MoCA points
         2. Laboratory markers
            1. Hemoglobin ________ g/L
            2. Hematocrit ________ %
            3. The level of glycated hemoglobin (in the presence of diabetes mellitus) ________ g/L
            4. Serum albumine ________ g/L
         3. Instrumental Methods
            1. Ejection fraction of the left ventricle ________ %
            2. Forced vital capacity1 ________
            3. Forced vital capacity ________
   4. Intraoperative factors
      1. Anesthesia type (select)
         1. Spinal FEpidural
         2. Combined spinal-epidural
         3. Combined inhalational
         4. Total intravenous anesthesia
         5. General with epidural anesthesia
      2. Intraoperative blood loss ________ mL
      3. Infusion volume ________ mL
      4. Need for vasopressors (Yes/No)
      5. Need for hemotransfusion (Yes/No)
      6. Type of anesthetic to maintain anesthesia _____________________________________________________________
      7. Muscle relaxation drug ________________________________________________________________________________
      8. Apply decurarization (Yes/No))
      9. Use of neuromuscular blockade monitoring (Yes/No)
   5. Postoperative factors
      1. Transfer to intensive care unit (Yes/No)
      2. Time to extubation after anesthetics are turned off ( ________ minutes)
      3. Postoperative cumulative balance by the end of the 1st day of the postoperative period ( ________ mL)
      4. Postoperative cumulative balance by the end of 3 days postoperative period ( ________ mL)
      5. Cognitive function on the 7th day after surgery ( ________ points)

2. Registered outcomes

   1. Outcome: died / was discharged from the hospital
   2. Observed postoperative complications and days of development after surgery
      1. Acute kidney injury ( ________ days)
      2. ARDS ( ________ days)
      3. Anastomotic failure ( ________ days)
      4. Arrhythmias ( ________ days)
      5. Cardiac arrest ( ________ days)
      6. Cardiogenic pulmonary edema ( ________ days)
      7. Postoperative delirium ( ________ days)
      8. Myocardial infarction ( ________ days)
      9. Pneumonia ( ________ days)
      10. Intestinal paresis ( ________ days)
      11. Postoperative bleeding ( ________ days)
      12. Pulmonary embolism ( ________ days)
      13. Acute cerebrovascular accident ( ________ days)
      14. Wound infection ( ________ days)
   3. Length of stay in the ICU ________ (days)
   4. Length of stay in the hospital ________ (days)
   5. 30 day outcome:
      1. death (Yes/No)
      2. readmission (Yes/No)

Date of inclusion in the study __________________________________

Date of final completion of the questionnaire ___________________